Position of nuclear medicine modalities in the diagnostic work-up of breast cancer.

Breast tumors can be imaged by different modalities: mammography is the most widely used technique because of its diagnostic value, patient compliance and low costs. Some techniques such as ultrasound (US) are often indicated, while others, such as digital mammography and magnetic resonance imaging (MRI) are still under evaluation and seem to be very promising. Among the nuclear medicine techniques breast scintigraphy with (99m)Tc-labelled lipophilic cations (SestaMIBI or tetrofosmin), positron emission tomography (PET) with 18F-2-deoxy-2-fluoro-D-glucose (FDG) have been evaluated in many clinical trials. At present breast scintigraphy has limited applications due to its poor spatial resolution, which has a minimum of 8 mm. It is questionable whether single photon emission tomography (SPECT) can offer any substantially better information on the breast; however, SPECT is more accurate in detecting axillary lymph nodes. Recent approaches using breast dedicated collimators and cameras have greatly improved the SPECT resolution and sensitivity. The most interesting technique offered by nuclear medicine today are PET and lymphoscintigraphy with the intraoperative detection of handled gamma probe. The sentinel node detection has achieved a large consensus of reliability and at present it has an important place in the clinical management. In the same time many authors have acknowledged the value of PET in the differential diagnosis of breast lesions and in locoregional staging, since breast cancer is strongly avid for glucose. PET demonstrated also its efficacy in detecting axillary lymph node metastases. Even in some clinical trials its accuracy proved nearly comparable to that of lymphoscintigraphy with sentinel node biopsy, other studies showed that PET scanning does not currently have adequate spatial resolution to detect both micro- and small macrometastatic disease in axillary lymph nodes. The added value of PET in breast cancer staging is that with a single examination PET allows the characterisation of breast lesions, in addition to complete viewing of the entire body. Whole-body PET may substitute other diagnostic assessments by examining the various regions of potential tumour spread. The current diagnostic work-up for pre- and postoperative staging includes various examinations: chest X-rays, US of the abdomen, mammography of the contralateral breast. Bone scintigraphy with (99m)Tc-diphosphonates and laboratory tests can also be considered in women with large tumors or in symptomatic patients. Computed tomography (CT) and MRI may be used in order to resolve particular diagnostic problems. The current application of some of these modalities depends on the risk of the single patient of developing metastatic spread, which is revealed by a number of prognostic parameters of tumor aggressiveness and of course, clinical stage. Bone scintigraphy and PET may be useful in monitoring therapy response and in detecting tumour relapses during follow-up. In particular PET guided by tumor markers measurements shows to detect more lesions than other non nuclear medicine modalities.